BLOG: Step therapy blues: Self-insured hospital system spikes Restasis

ByDarrell E. White, MD

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

Oh, this is rich. Have you seen those Geico commercials where Dikembe Mutombo blocks all the “shots”?

Yah, that’s gotta be the explanation for the recent preauthorization denial we got for a Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) prescription. Somebody somewhere in the employee benefits office at World Class Hospital here in Cleveland is running around and cackling like a bad karaoke imitation of Mr. Mutombo after rejecting my poor patient’s layup of a prescription.

I mean, how else can you explain such a thing?

Darrell E. White

My patient has a SPEED score of 26 (higher than 6 is abnormal). There is conjunctival staining in both eyes, and the tear breakup time is 3 in both eyes. For those of you keeping score at home, this is a highly symptomatic patient with evaporative dry eye and clear evidence of ocular surface inflammation who would be treated with an immunomodulator under any circumstances. That they also wish to have laser refractive surgery (which will make them temporarily dryer) so that they can move away from the pro-drying effect of their contacts makes the immunomodulator prescription even more important.

You know what we got back from the preauth? “The patient only has one value for dry eye. Restasis is not approvable until a two-month trial of (list of artificial tears) is unsuccessful.” We got step therapied by a major medical institution that wants us to use a non-therapeutic treatment before we are “allowed” to prescribe an FDA-approved medication. World Class Hospital has a very famous ophthalmology service, the Anthracite Eye Center. Do you think the HR hacks doing preauth on dry eye prescriptions make the good doctors at Anthracite Eye do a 2-month trial of artificial tears before they give the A-OK for Restasis coverage?

Step therapy of all kinds is a big issue for our AAO leadership. You’ll excuse me for being pessimistic about their efforts to derail step therapy by health insurance companies. Self-insured medical institutions like World Class Medicine are blocking their own employees from having access to standard of care treatment with medicines like Restasis.

Dikembe Mutombo would be proud.

Published by: